Dental Tribune | March, 2009

Clinical 9

Minimally invasive and biomimetic goal, to retain as much of the natural

tissue as practical, and to mimic the
physics and structures of the human

endodontics: The final evolution?

David J. Clark, DDS the words of Dr. Eric Herbransen,
the endodontics succeeds often in
tooth retention.
In contrast, the supposed strength-
body. There is nothing biomimetic
about a stiff, round rod (prefabricat-
ed post) running through the center
of an ovoid root.
The natural ovoid root is essen-
tially a semi-rigid pipe deriving its
strength from without, not within.

T
raditional endodontics has been
based on feel, not sight. Tactile
proprioreception was the only
guide as burs and files were blindly
inserted into pulp chambers and
root canal systems. Together with
radiographs and electronic apex
locators, this blind approach has
produced surprising success that, in
Fig. 1: An immature maxillary molar is sectioned
and viewed from the apical aspect.
Fig 2: This lower bicuspid was treated with a
generous crown-down endodontic shape and
suffered a retrograde root fracture within three
years of the endodontic treatment.
Figure 3: This radiograph demonstrates a thirty-
one year success with delicate shaping and crude
obturation with silver points (#14), and a four-year
failure with a large crown-down shape and heated
gutta-percha (note the lesion on #13).
spite of us. ening of the root from a monoblock The endodontic and endo-restorative
There is, however, a significant of bonded resin obturation, bonded goal should be to mimic the pulp
failure rate, especially long-term core and fiber post is proving to space that was present when the
failure, that is driving mainstream be inconsistent.1 Another startling tooth was young. From that point,
dentistry to aggressively extract nat- revelation is that the dentin in an it can be argued that any secondary
ural teeth in favor of implants. The endodontically treated tooth is not dentin that is deposited adds little
sting of clinical failure is a powerful more brittle than in a vital tooth.24 In additional strength because of the
motivator for change. In this article, I short, preservation of peri-cervical amorphous and irregular deposition
will describe the rationale and tech- dentin and ferrule girth trump all pattern. This point is supported by
niques involved in minimally trau- other factors. the robust strength of young teeth
matic endodontic access and shaping with large pulp chambers and large
(Part I). In my upcoming Webinar I Ovoid canal systems & roots are non-round radicular pulp spaces.
will discuss obturation techniques for a reason If a small round access that does
for smaller and non-round endodon- Rotary instruments and obturat- not disturb primary dentin can allow
tic shapes, which will also appear as ing points of gutta-percha are round instruments to engage potentially
a follow up article in this publication because of the limitations of their significant complex anatomy (e.g.,
(Part II). mechanical nature. They create ana- a second or third major system and
tomically appropriate shapes in round corresponding portals of exit), then
Ribbons, sheets & banners roots, but fail in ovoid roots. Over the the round access is acceptable. The
One of the most distressing hang- ages, the dynamics of occlusion and reality of ovoid roots would seem to
overs of the era of blind endodontics arch form have guided the develop- disagree with this approach.
and endo-restorative is the belief that ment of human tooth roots such that Creating a large round access that
canal systems are straight, exit at the at least half have ovoid roots. results in removal of primary dentin
radiographic apex and are round in of the delicate, narrow portion of
cross section. In reality, most canal Smaller and/or ovoid shaping: Why and how? the root is the common approach
systems curve and exit short of the Why Biomimetics is a treatment today. While this can allow access to
radiographic terminus. A very large approach that has, as its ultimate complex branching of systems that
number, at least 50 percent, are ovoid
AD
or super-ovoid in cross section. Fig-
ure 1 demonstrates that of the three
roots and canal systems shown, only
one is round. As these canal systems
mature, they narrow into a variety
of unpredictable ovoid shapes often
with smaller anastamosing canal sys-
tems (Figs. 46).
The evolution of endodontic shaping
The original endodontic shape was
established based on mostly hand fil-
ing and filled with either silver points
or cold lateral condensation of gutta-
percha. Sargenti later introduced a
more rapid approach that involved
machine-driven instruments (rotary
files) creating larger shapes with
significantly more dentin removal.
As of late, a crown down approach
is now popular. The roots are rap-
idly and blindly machined. This can
result in better obturation of the
apical half because of improved pen-
etration of irrigation during instru-
mentation and improved hydraulics
during obturation. But at what cost
(Fig. 2)?

Is crown down endo actually better than lat-

Fig. 4: This mandibular incisor appears so frail with
a lingual view or radiographic image. It appears
husky with a mesial view. It is at least twice as
broad buccal lingually.
eral condensation?
The outcome studies are inclu-
sive, but what we do know is that
the success rate today is no better
than it was 40 years ago (Fig. 3).
The advantages of crown down are
often offset by the weakening caused
by Gates-Glidden burs and orifice
shapers. The short-term thrill of the
radiographic puff of sealer at the
apex is lost when the tooth implodes
a few years down the line. Residual
dentin is directly related to long-
term strength and has indisputably
been shown as the key to long-term
10 Clinical Dental Tribune | March, 2009
endodontics
From Page 9
occurs further apically, it does not
satisfy the more appropriate goals
of anatomic, biomimetic dentistry.
Additionally, the single large round
endodontic shaping pattern often
Figs 5: One variation of potential anatomy in an
ovoid root; system branches in apical third of a
C-shaped second molar.
Fig. 6: Another variation of ovoid roots, non-round
systems branch into five systems in the coronal
third. (Image courtesy Dr. John Khademi)
Figs. 7, 8: Several renderings contrast current
endodontic shapes versus new biomimetic
microscope enhanced shapes. Figure 7 shows the
preoperative pulpal space of the root, sectioned
at the orifice, then shows lateral condensation
shape that does not weaken the root but also does
not address the potential complex anatomy. Next
image shows the new aggressive crown-down shape
that weakens non-round roots. Figure 8 shows two
potential shapes that are anatomic, address the
complex anatomy and yet do not weaken the tooth.
Figure 8a shows the obturated anatomic shapes in
the second axis.
encroaches upon a fluting in the
center of the root.
How: visually shaping ovoid sys-
tems The three components of ovoid
shaping are:
1) the operating microscope with
powerful coaxial shadowless light-
ing,
2) ultrasonic instruments, and
3) an understanding of the anato-
my of ovoid roots.
Anatomic, biomimetic shaping
cannot occur safely by feel (Figs.
7, 8).
Summary
Although no two roots are the
same, general anatomic patterns
allow the microscope-equipped cli-
nician to search for major pulpal
regions that will yield a high prob-
ability of cleaning and shaping the
Fig 9: A new model for lower incisor access is
depicted, along with the new CK endodontic access
bur. Note that the access has been moved away
from the cingulum and towards the incisal edge.
The delicate tip size of the bur and its conical
shape are helpful to both visual (dentists using
microscopes) and tactile (little or no magnification)
endodontics.
Fig. 10a. Extracted bicuspid is shaped to follow the
pattern of secondary dentin that has been described
by Carr as resembling glacial ice in appearance
under the microscope. One border of secondary
dentin and primary dentin is outlined with arrows.
Glacial ice is one of the many terms used to
describe the many color and translucency features
of secondary and tertiary dentin. CPR 2D (Obtura-
Spartan) ultrasonic tip is pictured at 16X.
Fig. 10b: Depicts the much finer CPR 5D as the
ovoid system is explored further apically with con-
stant microscopic visualization. Note the ideal visual
environment that is the hallmark of the microscope-
ultrasonic combination. It allows for identification of
dentin maps for the ultimate in dentin preservation.
Table 1: New Microscope-Enhanced Protocol
1. I nitial access with round-ended carbide or diamond burs. For incisors
and canines, the new CK endo access burs provide optimum safety
and dentin preservation (Fig. 9).
2. G
 ross de-roofing with tapered diamond burs, retaining a small sof-
fit.
3. P
 rovide straight-line access sweeping away from high-risk anatomy
with the CPR-2D.
For ovoid systems
4. Sweep the coronal of the ovoid system with the CPR-2.
5. Sweep the next or with the CPR-4D or 5D (Fig. 10b).
6. I rrigate, dry with the Stropko syringe and then evaluate at 1624x for
multiple systems that branch in the apical half.
7. Begin filing.
clinically available pulpal zones. The
shapes that were introduced during
About the author
the Schilder era have served as a
Dr. David Clark
transitional technique to allow the
founded the Acad-
first real three-dimensional compac- emy of Micro-
tion of gutta-percha. Endodontics is, scope Enhanced
in reality, a restoratively driven pro- Dentistry and is
cedure; and minimally invasive and a course director
biomimetic principles will require at the Newport
different skills and materials to Coast Oral Facial
shape, pack and restore these non- Institute. He lec-
round canal systems. tured for Clinical
Research Associates in the Update
Series. In addition, Clark authored
References the first comprehensive guide to
1. Tay FR, Pashley DH. Monob- enamel and dentinal cracks based on
locks in root canals: A hypotheti- 16 power magnification, and numer-
cal or a tangible goal. J Endod ous articles relating to minimally
2007;33;4:391398. invasive dentistry, biomimetic endo-
2. Sathorn S, Palamara JE, Messer dontic shaping, diastema closure and
advanced magnification. Clark helped
HH. A comparison of the effects
pioneer the concept of biomimetic
of two canal preparations on root
micro-endodontics. He serves as an
fracture susceptibility and fracture
opinion leader for restorative den-
pattern. J Endod 2005;31;4:283
tistry and endodontics, introduced the
287.
Clark Class II for posterior compos-
3. Sedgley CM, Messer HH. Are endo- ites and developed the Bioclear Matrix
dontically treated teeth more brit- System.
tle? J Endod 1992;18(7);332335.
4. Huang TJ, Schilder H, Nathanson 3402 S. 38th St
D. Effects of moisture content and Tacoma, Wash. 98409
endodontic treatment on some Tel.: (253) 472-4292
mechanical properties of human Fax: (253) 474-7708
dentin. J Endod 1992;18(5);209 drclark@bioclearmatrix.com
215.
Attend Dr. David Clarks Webinar!
On March 14 at 1:45 p.m. E.S.T., Dr. Clark will present a one-hour Webinar, World
Class Obturation for General Dentists, followed by a live question and answer session
with the online audience.
Can endodontics be minimally invasive? Biomimetic? Last as long as
implants?
The implant era has raised the bar for endodontics, serendipitously as
new tools and techniques allow for the next level of endodontic excel-
lence. Instead of blindly poking around the pulp chamber and machin-
ing the delicate root with Gates Gliddens and large rotary files, there
are other options! Once we have created the new shapes, then how can we
perform ideal obturation? Join us to find out!
This is one Webinar in a fivepart Webinar series that will be running
over the course of the entire day to launch the brand new Dental Tribune
Study Club. Participants will receive C.E. credits and attendance is free
for the first 100 registrants. After the first 100 spaces are filled, the cost of
the full-day symposium is only $49. Live attendees have 30-day access to
the recorded Webinars to review at their convenience. Attendees require
an online computer with audio capabilities. Please register under www.
DTStudyClub.com. Upon registration, you will be provided with a pass
code. Hurry to be one of the first 100!